HospitalInspections.org

Based on medical record review, interview and policy review it was determined the Facility failed to address the use of restraint or seclusion for safety on the Patient's Treatment Plan for 6 of 12 patients restrained or secluded. Failure to address the use of restraints or seclusion on the Patient's Treatment Plan did not ensure staff were aware of what had been determined as treatment or change in treatment based on the last episode of restraint or seclusion for safety. Findings follow:
1. Policy # ASH 05.01.07 VII Caring For A Patient In Restraint or Seclusion: 11. If a patient requires Restraint or Seclusion for safety, the patient's Treatment Plan must address this issue.
2.A. Review of the medical record for Patient #1 revealed Patient #1 was placed in seclusion on 02-25-17. On the Seclusion & Restraint Form Patient Behavior requiring Seclusion /Restraint "He was a threat to others". Review of the Treatment Plan for Patient #1 revealed no Treatment Plan Addendum that addressed the Seclusion of Patient #1 on 02-25-17. The above was verified by the Regulatory Compliance Quality Director at 1430 on 03-16-17.
B. Review of the medical record for Patient #2 revealed Patient #2 was placed in seclusion on 03-04-17. On the Seclusion & Restraint Form Patient Behavior requiring Seclusion/Restraint-"Serious threat to harm self/other(s)". Review of the Treatment Plan for Patient #2 revealed no Treatment Plan Addendum that addressed the seclusion of Patient #2 on 03-04-17. The above was verified by the Regulatory Compliance Quality Director at 0900 on 03-16-17.
C. Review of the medical record for Patient #3 revealed Patient #3 was placed in seclusion on 03-05-17. On the Seclusion & Restraint Form Patient Behavior requiring Seclusion/Restraint-"Assaulted staff". On 03-14-17 Patient #3 was placed in seclusion. On the Seclusion & Restraint Report Patient Behavior requiring Seclusion/Restraint-"Assaulted staff and Serious threat to self /other(s)". Review of the Treatment Plan for Patient #3 revealed no Treatment Plan Addendum that addressed the seclusion of Patient #3 on 03-05-17 and 03-14-17. The above was verified by the Regulatory Compliance Quality Director at 0905 on 03-16-17.
D. Review of the medical record for Patient #4 revealed Patient #4 was placed in seclusion on 03-04-17. On the Seclusion & Restraint Report Patient Behavior requiring Seclusion/Restraint "Serious threat to harm self/other(s)". Review of the Treatment Plan for Patient #4 revealed no Treatment Plan Addendum that addressed the seclusion of Patient #4 on 03-04-17. The above was verified by the Regulatory Compliance Quality Director at 1110 on 03-17-17.
E. Review of the medical record for Patient #5 revealed Patient #4 was placed in seclusion on 02-15-17. On the Seclusion & Restraint Report Patient Behavior requiring Seclusion/Restraint "Assaulted staff". Review of the Treatment Plan for Patient #5 revealed no Treatment Plan Addendum that addressed the seclusion of Patient #5. The above was verified by the Regulatory Compliance Quality Director at 1110 on 03-17-17.
F. Review of the medical record for Patient #6 revealed Patient #6 was placed in seclusion on 01-17-17 On the Seclusion & Restraint Report Patient Behavior requiring Seclusion/Restraint "Assaulted staff". Review of the Treatment Plan for Patient #6 revealed no Treatment Plan Addendum that addressed the seclusion of Patient #6. The above was verified by the Regulatory Compliance Quality Director at 1115 on 03-17-17.